Semiology of arthopathies and its complications

Size: px

Start display at page:

Download "Semiology of arthopathies and its complications"

Meryl Simon
6 years ago
Views:

1 Semiology of arthopathies and its complications Poster No.: C-1029 Congress: ECR 2013 Type: Educational Exhibit Authors: M. Caba Cuevas, E. M. Ocón Alonso, D. M. Castaño Palacio, I. Zabala Martín-Gil, S. Llorente Galán, N. Gómez León; Madrid/ES Keywords: Pathology, Diagnostic procedure, CT, MR, Radiografía simple, Musculoskeletal soft tissue, Musculoskeletal bone DOI: /ecr2013/C-1029 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 45

2 Learning objectives To identify radiologic findings of most common arthropathies in clinical practice. To evaluate the usefulness of magnetic resonance imaging (MRI), in the evaluation of complications Background 1. INTRODUCTION 2. INFLAMMATORY ARTHRITIS - Rheumatoid arthritis - Seronegative Spondyloarthropathies 3. CRYSTAL DEPOSITION ARTHROPATHIES - Gouty Arthritis (Monosodium Urate Crystal deposition disease) - Calcium Pyrophosphate Dihydrate (CPPD) Crystal Deposition Disease 4. CONNECTIVE TISSUE ARTHRITIS - Scleroderma - Dermatomyositis 5. ARTHROPATHIES COMPLICATIONS... Page 2 of 45

3 1. INTRODUCTION The arthropathies specific diagnosis is based upon: 1. Clinical data 2. Laboratory features 3. Radiographic features: A slow, insidious onset, with developing symptoms over several months required an Xray study including: - PA and oblique projection of both hands - AP projection of both knees - AP projection of pelvis - Lateral projection in cervical spine flexion. 2. INFLAMMATORY ARTHROPATHIES 2.1 RHEUMATOID ARTHRITIS (RA) It is an autoimmune disease characterized by chronic inflammation of synovial joints. It is more common in women (2-3:1). Starting age between 20 and 55 years. Clinical presentation: polyarthralgia, morning joint stiffness, nonspecific general symptoms (fatigue, weight loss, fever). Positive rheumatoid factor (75%). Localization: HANDS AND FEET (80-90%) (Figures 1 and 2), knees (80%), cervical spine (50%) Peripheral skeleton injuries distribution is BILATERAL and SYMMETRICAL Typical radiologic changes in involved joints: Subluxations Osteoporosis Uniform decreased joint space Erosions Soft tissue swelling Page 3 of 45

There are two phases with early and late radiographic changes: Radiologic Changes of Early Rheumatoid Arthritis (figure 3) 1. Joint space widening (earliest and most transient finding) 2.

4 There are two phases with early and late radiographic changes: Radiologic Changes of Early Rheumatoid Arthritis (figure 3) 1. Joint space widening (earliest and most transient finding) 2. Soft tissue swelling usually symmetrical at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints 3. Periarticular osteoporosis 4. Partial or complete interruption of the cortical white line on the radial aspect of the fourth and fifth metacarpal heads representing subtle erosions. 5. Marginal erosions on the bare areas of bone, at MCP and PIP joints. Fig. 3: Radiograph (detail view) of the hand shows radiologic changes of early RA a. Periarticular osteoporosis b. Subtle erosions on the radial side of proximal phalanges c. Soft tissue swelling References: Hospital Universitario La Princesa - Madrid/ES Radiologic Changes in late-stage rheumatoid arthritis (figures 4, 5, 6 and 7) Soft tissue inflammatory destruction causes joint subluxation or luxation, most frequently ulnar deviation of the second to fifth MCP joints Erosions may lead to severe destruction and mutilation with bone deformity. Diffuse osteoporosis Uniform and symmetrical joint space narrowing In advanced stages the inflammatory injury may lead to bony ankylosis Page 4 of 45

Fig. 4: Radiograph of the hand shows radiologic changes of late-stage RA: Subluxations with ulnar deviation of the second to fifth MCP joints, diffuse

5 Fig. 4: Radiograph of the hand shows radiologic changes of late-stage RA: Subluxations with ulnar deviation of the second to fifth MCP joints, diffuse osteoporosis and symmetrical joint space narrowing of the MCP, PIP and carpal joints. References: Hospital Universitario La Princesa - Madrid/ES Page 5 of 45

6 Bilateral and symmetrical involvement of foot joints (80-90%) (Figure 8) is another typical manifestation of RA. Later in the course of the disease, large joints like knees (80%) (Figure 9), and cervical spine (50%) may be affected. (Figure 10) Fig. 8: Radiograph of the feet shows Subluxation with peroneal deviation of the 2th to 5th metatarsaphalangeal (MTP) joints, hallux valgus and erosions on the phalanges base and metatarsals head. Tarsal ankylosis. References: Hospital Universitario La Princesa - Madrid/ES 2.2 SERONEGATIVE SPONDYLOARTHROPATHIES It is a general term for a group of arthritis disorders that involve predominantly cartilaginous joints and entheses and may have overlapping symptoms (low back pain, back stiffness...). The subtype of Page 6 of 45

spondyloarthropathies is usually distinguished on the basis of patient history and clinical findings. 2.2.1 Ankylosing spondylitis 2.2.2 Psoriatic arthritis 2.2.3 Arthritis associated with inflammatory bowel disease 2.

7 spondyloarthropathies is usually distinguished on the basis of patient history and clinical findings Ankylosing spondylitis Psoriatic arthritis Arthritis associated with inflammatory bowel disease ANKYLOSING SPONDYLITIS It is a chronic and progressive inflammatory arthritis. It is more common in men (3:1). Starting age between 20 and 55 years. It has been shown to have a strong association with HLA B27. It manifests as a bilateral and symmetrical arthritis of the axial skeleton that involve the sacroiliac joint and the spine. Typical radiologic findings: Sacroiliac joint (Figure 11) The early changes of the disease are detected at the sacroiliac joint as a loss or blurring of the subchondral cortex. It is followed by the development of small erosions ("rat bite erosions") along the iliac side of the joint. As the disease progress the erosions become larger and sclerosis around the joint becomes more prominent. In late stages joint ankylosis develops. Fig. 11: Radiograph of the pelvis shows changes at the sacroiliac joint. a. Small erosions (grade II sacroiliitis) b. Bone ankylosis at the sacroiliac joint. Right hip joint space narrowing. Left hip prothesis. Bamboo cane column. Page 7 of 45

References: Hospital Universitario La Princesa - Madrid/ES Spine (Figure 12) Radiologic changes begin symmetrically at lumbar spine and extend to dorsal and cervical spine.

8 References: Hospital Universitario La Princesa - Madrid/ES Spine (Figure 12) Radiologic changes begin symmetrically at lumbar spine and extend to dorsal and cervical spine. Romanus lesions: small erosions at the anterior corner of the vertebral body. Syndesmophytes: new bone formation along the anterior aspect of the vertebral body. Square vertebral bodies The ligaments may ossify and give the image of "bamboo cane column". Ankylosis of the facet joints. Fig. 12: Radiograph (detail view) of the lumbar spine a. Syndesmophytes b. Square vertebral bodies c. Bamboo cane column References: Hospital Universitario La Princesa - Madrid/ES Enthesitis: typical locations include the iliac crest, ischial tuberosity, greater trochanter, calcaneus and greater tuberosity) Other joints involved include hip, shoulder and knee PSORIATIC ARTHRITIS Page 8 of 45

1. 2. 3. 4. Psoriasis is a chronic inflammatory disease of the skin. It has a prevalence of 1-2% of the population. Psoriatic arthritis affects 5-8% of the psoriatic population.

9 Psoriasis is a chronic inflammatory disease of the skin. It has a prevalence of 1-2% of the population. Psoriatic arthritis affects 5-8% of the psoriatic population. Nail involvement is the only clinical feature indicating that patients with psoriasis are likely to experience arthritis. It has and equal male to female ratio. Starting age between 30 and 50 years. Patients may have variable clinical presentation: monoarthritis or oligoarthritis with enthesitis, or axial involvement (sacroiliac joint and spine). The most frequent presentation is as a bilateral and asymmetric oligoarthritis that involve PIP and distal interphalangeal (DIP) joints of hand and foot. Dactylitis, a fusiform soft tissue swelling, is a characteristic feature of psoriatic arthritis seen in one third of patients. Typical radiologic findings: (Figure 13) Normal mineralization Bone erosions: typically begin at the margins of the joint and progress along the articular surface giving "pencil in cup" images in late stages. Bone proliferation is prominent and is the most typical feature (adjacent to erosions or at the enthesis). Soft tissue swelling (sausage toe) Page 9 of 45

10 Fig. 13: Radiograph (detail view) of the hand shows: a. Bone erosions at DIP joints b. Bone proliferation adjacent to PIP joints and soft tissue swelling (sausage toe) c. "Pencil in cup" erosions in late stage psoriatic arthritis. References: Hospital Universitario La Princesa - Madrid/ES ARTHRITIS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE It is an arthritis associated with inflammatory bowel disease (ulcerative colitis, Crohn disease, Whipple disease) Arthritis lesions may affect the axial and peripheral skeleton It is more frequent as a bilateral and symmetrical sacroiliitis, similar to ankylosing spondylitis. Changes that affect the spine can include syndesmophytes and square vertebral body (Figure 14) 3. CRYSTAL DEPOSITION ARTHROPATHIES 3.1. GOUTY ARTHRITIS It is a metabolic disease characterized by acute arthritis in early stage and monosodium urate monohydrate crystals deposits (tophi) within or around the joints in advanced stages (chronic tophaceous gout) More frequent in males (20:1) and postmenopausal women. Predominant in males (20:1). Articular involvement distribution is variable, but it is most frequently as an asymmetric and POLYARTICULAR disease. The disease shows predilection for lower extremity joints. The most common sites are the feet (first toe), ankle, knee and elbow. Typical radiologic findings of chronic tophaceous gout (Figure 15) Normal mineralization Normal joint space Eccentric erosions with sclerotic borders Overhanging edges bones Tophi: usually asymmetric soft tissue masses around the joint.tophi may also locate intraosseous, intraarticular or around enthesis or extensor tendons (quadriceps, triceps, Achilles tendon) Page 10 of 45

11 Fig. 15: Radiologic findings of chronic tophaceous gout a. Radiograph (detail view) of the foot shows erosion with sclerotic rim in the 1st MTF b. Radiograph (detail view) of the hand shows overhanging edges bones c. Radiograph (detail view) of the elbow shows a calcified tophus References: Hospital Universitario La Princesa - Madrid/ES 3.2 CALCIUM PYROPHOSPHATE DIHYDRATE (CPPD) CRYSTAL DEPOSITION DISEASE It is the most common crystal deposition disease. It is characterized by acute, subacute or chronic joint inflammation with deposition of CPPD crystal in hyaline cartilage, fibrocartilage and other soft tissue structures. It affects middle-aged and elderly people. The clinical presentation is highly variable. Indeed the disease has been called a "great mimicker" of other arthritides. It is frequently presented as a form of arthritis that simulates osteoarthritis with an acute inflammatory component. It most common affects knee and hand (MCP) joints. Typical radiologic findings: (figure 16) Chondrocalcinosis (knee, symphysis pubis, wrist) Normal mineralization Joint space uniform narrowing Subchondral cysts are one of the hallmarks of this arthritis. They are usually larger and more numerous than in osteoarthritis Osteophytes are common but less frequent than in osteoarthritis. 4. CONNECTIVE TISSUE ARTHROPATHIES Page 11 of 45

12 4.1. SCLERODERMA It is a multisystemic disease characterized by dermal or internal fibrosis (localized and generalized forms) Affects young women. Age: years old. Most frequent: CREST Syndrome Typical radiologic findings (figure 17) It usually causes no articular erosions Acroosteolysis (distal phalanges of the hand) Subcutaneous and periarticular calcification Distal fingers soft tissue atrophy 4.2. DERMATOMYOSITIS Soft tissue calcification in upper and lower extremities proximal musculature. Usually no articular erosions Juxtaarticular osteoporosis 5. ARTHROPATHIES COMPLICATIONS Arthropathies progression and complications due to pharmacological treatments side effects (corticoid, nonsteroidal antiinflammatories, immunosuppressives, and biologic therapies) are assessed with computed tomography (CT) and MRI. We describe complications, on one hand because of the immunosuppression therapy, and on the other hand due to osteoporosis, either because of the disease or as a secondary pharmacological effect that facilitates the appearance of fractures. We show the most outstanding cases. CASE 1. Osteomyelitis in a patient with RA. A 72-year-old man with RA. He had been treated with leflunomide. In the right foot sole he suffered ulceration with swelling and erythema. Radiograph of the foot (figure 20) and MRI are requested to complete the study (figures 21, 22 and 23) Page 12 of 45

Fig. 21: Right foot MRI. Sagittal unenhanced fast spin-echo T1 weighted image (fig 21) shows a hypointense lesion in the distal half of the 5th metatarsal bone marrow.

13 Fig. 21: Right foot MRI. Sagittal unenhanced fast spin-echo T1 weighted image (fig 21) shows a hypointense lesion in the distal half of the 5th metatarsal bone marrow. This lesion is bright in short tau inversion recovery (Stir) (fig 22), and shows peripheral enhancement after contrast administration (fig 23). It is consistent with osteomyelitis and intraosseous abscess. A plantar ulcer with inflammatory changes in the subcutaneous cellular tissue is shown. References: Hospital Universitario La Princesa - Madrid/ES Page 13 of 45

14 Fig. 22 References: Hospital Universitario La Princesa - Madrid/ES Page 14 of 45

15 Fig. 23 References: Hospital Universitario La Princesa - Madrid/ES CASE 2. Vertebral fractures in a patient with ankylosing spondylitis. A 65 year-old-patient with ankylosing spondylitis. He had intense dorsolumbar pain after a traumatism. Page 15 of 45

16 Figures 24 and 25. Spine MRI Page 16 of 45

17 Fig. 24: Spine MRI.Lower half T9 and upper half T10 vertebral bodies bone marrow shows low signal intensity in unenhanced fast spin-echo T1-weighted image (fig 24) and increased signal on fat-saturation fast spin-echo T2-weighted image (fig 25) relative to trabecular fractures and bone bruises. A fracture line is seen on the right lamina of T9 (fig 24).An interspinous ligament tear with liquid, bright in T2-weighted image(fig 25) References: Hospital Universitario La Princesa - Madrid/ES Page 17 of 45

18 Fig. 25 References: Hospital Universitario La Princesa - Madrid/ES Figure 26. Spine MRI (sidebar) Page 18 of 45

CASE 3 Right hip avascular necrosis in a patient with RA A 41 year-old- women with RA treated with corticoids and methotrexate. She began suffering pain at the right hip several months ago. Fig.

19 CASE 3 Right hip avascular necrosis in a patient with RA A 41 year-old- women with RA treated with corticoids and methotrexate. She began suffering pain at the right hip several months ago. Fig. 27: Radiograph of the pelvis shows asymmetrical joint space narrowing at the right hip. The left hip appears normal. References: Hospital Universitario La Princesa - Madrid/ES The study was completed with a pelvis MRI (figures 28 to 31) Page 19 of 45

20 CASE 4 Trabecular fracture of the tibia in a patient with psoriatic arthritis A 67 year-old-woman with Psoriatic arthritis treated with leflunomide and methotrexate. She had pain at the left ankle without previous trauma. Fig. 32. Left ankle MRI Page 20 of 45

21 Fig. 32: Left ankle MRI. Sagittal unenhanced fast spin-echo T1-weighted image shows multiple irregular hypointense lines in the lower third of the tibia relative to trabecular fractures. References: Hospital Universitario La Princesa - Madrid/ES Page 21 of 45

22 Fig. 33: Left ankle MRI. Sagittal Stir image shows a diffuse area of signal increased relative to bone bruise References: Hospital Universitario La Princesa - Madrid/ES CASE 5 Severe osteoporosis complicated with vertebral fractures in a patient with RA. Page 22 of 45

23 A 76 year-old-woman with RA. She had received multiple treatments (gold salts, leflunomide, infliximab). She was in treatment with corticoids and methotrexate. She had acute dorsolumbalgia after a traumatism. Figure 34 and 35. Spine MRI Page 23 of 45

24 Fig. 34: Spine MRI.Sagittal unenhanced fast spin-echo T1-weighted (fig 34) image shows severe fracture of the T8 vertebral body with bone marrow edema (fig 35) and a trabecular fracture line of the T9 vertebral body. T8 vertebral body shows a slight displacement of the posterior wall that decreases the anterior subarachnoid space. References: Hospital Universitario La Princesa - Madrid/ES Page 24 of 45

25 Fig. 35 Page 25 of 45

26 References: Hospital Universitario La Princesa - Madrid/ES Images for this section: Fig. 1: Radiograph of the hand shows articular involvement of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, with normal distal interphalangeal joint. Page 26 of 45

27 Fig. 2: Scaphoid, styloid apophysis of the radius and ulna are frequently involved. Page 27 of 45

28 Fig. 5: Radiograph (detail view) of the hand shows symmetrical joint space narrowing of MCP joints. Page 28 of 45

29 Fig. 6: Radiograph (detail view) of the hand shows subchondral erosions. Page 29 of 45

30 Fig. 7: Radiograph (detail view) of the hand shows Bony ankylosis. Page 30 of 45

31 Fig. 9: Radiograph of the knees shows symmetrical and bilateral joint space narrowing Page 31 of 45

32 Fig. 10: Radiograph of the cervical spine shows Atlantoaxial subluxation Page 32 of 45

33 Fig. 14: Radiograph of the pelvis shows bilateral sacroiliitis in a patient with ulcerative colitis Page 33 of 45

34 Fig. 16: Radiograph of the knees shows a. Chondrocalcinosis b. Joint space narrowing of the patellofemoral joint Page 34 of 45

35 Fig. 17: Radiograph of the hand shows: a. Soft tissue calcification b. (detail view) Acroosteolysis c. Soft tissue atrophy. Deformities and subluxation. Fig. 18: Radiograph of the pelvis shows calcification in the proximal musculature of lower extremities Page 35 of 45

36 Page 36 of 45

37 Fig. 19: Radiograph of the forearm shows extensive soft tissue calcification Page 37 of 45

38 Page 38 of 45

39 Fig. 20: Radiograph of the foot shows a lytic lesion with cortical erosion in the 5th metatarsal head. Severe involvement of all MTF joints. Enchondroma in the proximal phalanx of the first toe. Fig. 26: Spine MRI. Axial unenhanced fast spin-echo T1-weighted image shows a fracture line on the spinous process of the T9 vertebra Page 39 of 45

40 Fig. 28: Pelvis MRI: Avascular necrosis of the right hip relative to corticoid therapy. Axial (fig 28) and coronal (fig 29) unenhanced fast spin-echo T1-weighted image shows a well defined hypointense geographic lesion delineated by a signal void rim in the weight bearing surface of the right femoral head. The lesion shows marked enhancement after intravenous contrast administration (fig 31). Coronal Stir (fig 30) image shows bone marrow edema that extends into the neck. Page 40 of 45

41 Fig. 29 Page 41 of 45

42 Fig. 30 Page 42 of 45

43 Fig. 31 Page 43 of 45

44 Imaging findings OR Procedure details Patients are studied with X-ray and MRI of 1.5 Teslas. Conclusion Plain radiography remains the fundamental imaging test in the initial evaluation of arthropathy. In the diagnosis of complications is essential the use of other imaging tests such as MRI, which allows establish the most suitable medical or surgical treatment. References Sommer J, Kladosek A, Volkmar W et al.rheumatoid Arthritis: A Practical Guide to State-of-the-Art Imaging, Image Interpretation, and Clinical Implications. RadioGraphics 2005; 25: Hermann K, Althoff C, SchneiderU.Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances. RadioGraphics 2005;25: Bennett D, Ohashi K, El-Khoury G. Spondyloarthropathies: ankylosing spondylitis and psoriatic arthritis. Radiol Clin N Am 2004; 42(1) Steinbach.Calcium pyrophosphate dihydrate and calcium hydroxyapatite crystal deposition diseases: imaging perspectives. Radiol Clin N Am 2004; 42(1) Monu J, Pope T. Gout: a clinical and radiologic review. Radiol Clin N Am 2004; 42(1) Tehranzadeh J, Ashikyan O. Advanced imaging of early rheumatoid arthritis. Radiol Clin N Am; 42 (1) Levine D, Forbat S, Saifuddin A. MRI of the skeletal manifestations of ankylosing spondylitis. Clin Rad ; Campagna R, Pessis E, Feydy A et al. Fractures of the ankylosed Spine: MDCT and MRI with emphasis on individual anatomic spinal structures. AJR 2009; 192: Page 44 of 45

45 Personal Information Page 45 of 45

Articular disease of the hand - the target joint approach

Articular disease of the hand - the target joint approach Poster No.: C-1817 Congress: ECR 2016 Type: Educational Exhibit Authors: R. R. Domingues Madaleno 1, A. P. Pissarra 1, I. Abreu 2, A. Canelas 1,